The most mysterious person in EMS is the medical director. Shrouded by the walls of the hospital or office, blissfully asleep at 3 a.m. while the ambulances roll, many paramedics wonder what exactly it is that the medical director does.

It might surprise you to know that as medical directors, we ask the same question. Although brief courses in EMS medical direction do exist, there really is no blueprint for the job. Many interested and enthusiastic physicians are unaware of the myriad roles and responsibilities that fall under the auspices of medical direction (we learn pretty quickly, though).

I like to be an active medical director, but as the years passed I noticed that more and more of my time was taken up with EMS matters. The State of Florida requires all licensed ALS providers to utilize the services of an EMS medical director. This physician is charged with supervising clinical care, developing protocols, approving trauma transport protocols and insuring the continuous availability of a physician to resolve EMS system problems. The doctor must also implement a quality management program, enforce medication security, review EMT refresher programs and participate as an EMS crewmember. On paper, not too great a task.

These sparse parameters seemed to belie the complexity of the job. I found myself enmeshed in multiple administrative, governmental and clinical liaisons. I was supervising paramedic clearance procedures, addressing system compliments and complaints and giving in-services to paramedics and EMTs. I was doing strategic planning and operational research, participating in disaster planning and emergency operations efforts and representing the EMS system within the community and the media. All these roles seemed necessary to ensure the level of care I felt our citizens deserved.

No matter how I tried to plan my day, it seemed like more work kept coming my way. I began to wonder if medical direction was as involved as I thought or if I was just making life too hard on myself. A research project held the promise of an answer.

I mailed a survey to all members of the Florida Association of EMS Medical Directors (FAEMSMD) in summer 2001. The survey assessed both system demographics and the activities of medical direction on paper (as in the written contract) and in practice. Multiple statistical techniques were used as appropriate; significance (p) was defined as <0.10 (you knew I was going to get statistics in here, didn t you?).

I received responses from 34 (45%) of FAEMSMD members. The mean number of EMS agencies served per contract was 2.85. Mean call volume was 43,860, and mean transport volume was 28,663. Two medical directors served large metropolitan areas, and when their statistics were removed from analysis, a more typical picture emerges with each physician serving an average of 1.81 EMS systems with 43,860 calls and 23,120 transports per year.

Twenty-five work parameters were examined in order to determine the differences between those roles the EMS medical director is contracted to perform and those actually performed in practice. These parameters were determined by reviewing not only the state requirements noted above, but by looking at job descriptions for the "model" medical director in the literature. Of the 25 parameters explored, 22 were performed in practice more frequently than by contract; 11 (44%) were performed significantly more often. The nature of these roles, responsibilities and duties, and differences between contracted and performed activities, are reflected in Table 1.

The identities of the most common contracted and performed roles was not really a surprise, as the majority were linked to statutory requirements. The most common contracted responsibilities were the management of a quality assurance program, the provision of 24/7/365 availability, protocol development, the promulgation of specific trauma transport protocols and attendance at administrative meetings. The list of most common performed responsibilities was nearly identical, with conflict resolution replacing transport protocol development in the pantheon.

What was of more interest was that virtually all of the parameters (22/25, 88%) were performed more frequently than were contracted. These differences were statistically significant differences in 11 (44%) of the 25 parameters studied.

For those who actually like statistics (and hey, who doesn t), it was interesting to note that roles and responsibilities exhibiting large frequency differences between contracted and performed categories did not always exhibit statistical significance. Notable examples of this phenomenon include the conflict resolution (44% contracted, 82% performed), attendance at national meetings (21% contracted, 53% performed) and research (18% contracted, 38% performed). The statistical reason for this is mostly linked to sample size. Nonetheless, there are great variances in the frequency of activities between contracts for medical direction and the actual job performance. In the real world, these variances cannot be ignored when discussing the workload of the medical director.

I have to be honest and say that I was hoping that EMS medical directors would turn out to be an overworked bunch. It would reinforce my feelings of persecution and justify my whining. But I was surprised by the stark differences between contracted and performed roles.

Of course, every study has its limits. Surveys administered by mail are prone to bias, and respondents will answer according to their own perceptions. The list of parameters used to illustrate the multiple roles of the medical director may not have been sufficiently comprehensive, the survey may have been too complex or inconvenient, and the sample size was relatively small. The study was based in Florida, and administrative and regulatory burdens in other states may impose different sets of roles and responsibilities upon the EMS physician.

One final caution is in order. While this effort tried to identify levels of professional activity for EMS physicians, it does not say what compensation and activity levels should be. I have my own bias toward full-time employment and appropriate compensation for EMS medical directors in large volume or complex, multi-agency systems.

Despite these cautions, this work gave me a better sense of what EMS medical directors actually do. It helped me get a better sense of perspective on what I was doing (probably working too hard, but so were a lot of other folks), and reinforced my feeling that EMS medical direction is evolving into a specialty with a unique scope of practice unknown to other clinicians. I m hopeful that works, such as these, will serve as a catalyst for a larger effort to fully evaluate the roles, responsibilities and compensation patterns of the EMS medical director.

While mystery may generate intrigue (anybody remember Greta Garbo?), perhaps it s time for medical direction to emerge from the shadows. Recognition of the multiple roles fulfilled by your EMS physician will be invaluable as EMS strives towards professionalism.